Erectile dysfunction (ED) is increasingly recognized as an early marker of systemic vascular disease, yet the role of exercise as a therapeutic intervention remains surrounded by significant controversy. Although mechanistic studies suggest that exercise enhances endothelial function and nitric oxide bioavailability, clinical trials show highly variable outcomes across populations. Key unresolved debates include: optimal exercise modality (aerobic vs resistance training), dose-response relationships, the complex interplay between exercise and testosterone, genetic determinants of treatment response, and potential risks in athletic populations (particularly cyclists). This rapid review critically examines these controversies, highlighting where consensus is lacking and where conflicting evidence demands further investigation. We argue that exercise prescription for ED requires a precision medicine approach that considers individual physiology, training status, genetic variants, and comorbidity profiles. Future research must move beyond heterogeneous protocols toward mechanistically-driven, personalized interventions that optimize vascular, hormonal, and molecular adaptations while minimizing potential adverse effects in specific populations. PATIENT SUMMARY: Exercise may improve erectile function, but the optimal prescription remains uncertain and should be personalized.
European urology focus. 2026 May 13 [Epub ahead of print]
Thomas Zandonai, Ana María Peiró, Inés Nuño, Ana Segura
Pharmacology, Health, and Addiction in Exercise Laboratory (PHAE Lab), Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernandez University of Elche, Alicante, Spain; Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, Alicante, Spain. Electronic address: ., Pharmacology, Health, and Addiction in Exercise Laboratory (PHAE Lab), Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernandez University of Elche, Alicante, Spain; Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, Alicante, Spain., Andrology Unit, Urology Department, Dr. Balmis General University Hospital, Alicante, Spain.